PATOFISIOLOGI PUA-I KARENA KONTRASEPSI
ALGORITMA TATALAKSANA PUA-I KARENA EFEK SAMPING KONTRASEPSI
4. Metode kontrasepsi dapat dilanjutkan
7.4. Algoritme tatalaksana PUA-I pada penggunaan AKDR
7.4. Algoritme tatalaksana PUA-I pada penggunaan AKDR
Gambar 19. Algoritma tatalaksana PUA-I pada penggunaan AKDR Keterangan:
1. Jika pada pemeriksaan pelvik dijumpai rasa nyeri, lanjutkan ke 2.
2. Berikan doksisiklin 2x100 mg sehari selama 10 hari karena pendarahan pada pertimbangkan untuk mengangkat AKDR.
3. Jika tidak dijumpai rasa nyeri dan AKDR digunakan dalam 4-6 bulan pertama,lanjutkan ke 4. Jika tidak, lanjutkan ke 5
4. Lanjutkan penggunaan AKDR, jika perlu dapat ditambahkan AINS. Jika setelah 6 bulan pendarahan tetap terjadi dan pasien ingin diobati, lanjutkan ke 5 (rekomendasi B)
5. Berikan PKK untuk 1 siklus
6. Jika pendarahan abnormal menetap lakukan pengangkatan AKDR. Bila usia pasien > 35 tahun lakukan biopsi endometrium
Tidak 1.Nyeripadauterus 2.Doksisiklin2x100mg/hariselama10 hari,pertimbangkanpengangkatan 4.LanjutkanpenggunaanAKDR,jika perludapatditambahkanAINS 5.BerikanPKKuntuk1siklus 4.Perdarahanabnormal berlanjutsetelah6bulan,atau pasieninginditerapi 6.Jikaperdarahanabnormal menetap,angkatAKDR,Pada pasienberusia>35tahun,lakukan biopsyendometrium Tidak Ya Ya 3.Penggunaan4Ͳ6bulanpertama LAMPIRAN
Tabel 1. Nilai laboratorium normal kadar hormon basal
Nilai normal SI Conventional
FSH (basal) 5-20 IU/L mIU/mL
LH (basal) 5-25 IU/L mIU/mL
E2 (basal) 70-220 pmol/L 20-60 pg/mL P (mid luteal) 6-64 nmol//L 2-20 ng/mL
Tabel 2.Nilai laboratorium normal Nama Pemeriksaan Nilai Rujukan Satuan Hemoglobin 11,7 – 15,5 g/dL Hematokrit 35 – 47 % Eritrosit 3,8 – 5,2 106/uL MCV 80 – 100 Fl MCH 26 – 34 Pg MCHC 32 – 36 g/dL Leukosit 3,6 – 11,0 103/uL Basofil 0 – 1 % Eosinofil 2 – 4 % Neutrofil 50 – 70 % Limfosit 25 – 40 % Monosit 2 – 8 % Trombosit 150 – 440 103/uL LED 0 – 20 mm/jam Waktuprotrombin 11,9 – 14,4 Detik APTT 23,6 – 34,8 Detik Fibrinogen 200 – 400 Mg/dL D-Dimer <500 Ng/mL GOT <27 U/L Gamma GT <39 U/L
Fosfatase Alkali 42 – 98 U/L
Cholesterol Total <200 mg/dL LDL Direk <100 mg/dL HDL >40 mg/dL Trigliserida <150 mg/dL Urean N 6 – 20 mg/dL SHBG 26,1 – 110 nmol/L TSHs 0,550 – 4,780 ulU/mL
7.4. Algoritme tatalaksana PUA-I pada penggunaan AKDR
Gambar 19. Algoritma tatalaksana PUA-I pada penggunaan AKDR Keterangan:
1. Jika pada pemeriksaan pelvik dijumpai rasa nyeri, lanjutkan ke 2.
2. Berikan doksisiklin 2x100 mg sehari selama 10 hari karena pendarahan pada pertimbangkan untuk mengangkat AKDR.
3. Jika tidak dijumpai rasa nyeri dan AKDR digunakan dalam 4-6 bulan pertama,lanjutkan ke 4. Jika tidak, lanjutkan ke 5
4. Lanjutkan penggunaan AKDR, jika perlu dapat ditambahkan AINS. Jika setelah 6 bulan pendarahan tetap terjadi dan pasien ingin diobati, lanjutkan ke 5 (rekomendasi B)
5. Berikan PKK untuk 1 siklus
6. Jika pendarahan abnormal menetap lakukan pengangkatan AKDR. Bila usia pasien > 35 tahun lakukan biopsi endometrium
Tidak 1.Nyeripadauterus 2.Doksisiklin2x100mg/hariselama10 hari,pertimbangkanpengangkatan 4.LanjutkanpenggunaanAKDR,jika perludapatditambahkanAINS 5.BerikanPKKuntuk1siklus 4.Perdarahanabnormal berlanjutsetelah6bulan,atau pasieninginditerapi 6.Jikaperdarahanabnormal menetap,angkatAKDR,Pada pasienberusia>35tahun,lakukan biopsyendometrium Tidak Ya Ya 3.Penggunaan4Ͳ6bulanpertama LAMPIRAN
Tabel 1. Nilai laboratorium normal kadar hormon basal
Nilai normal SI Conventional
FSH (basal) 5-20 IU/L mIU/mL
LH (basal) 5-25 IU/L mIU/mL
E2 (basal) 70-220 pmol/L 20-60 pg/mL P (mid luteal) 6-64 nmol//L 2-20 ng/mL
Tabel 2.Nilai laboratorium normal Nama Pemeriksaan Nilai Rujukan Satuan Hemoglobin 11,7 – 15,5 g/dL Hematokrit 35 – 47 % Eritrosit 3,8 – 5,2 106/uL MCV 80 – 100 Fl MCH 26 – 34 Pg MCHC 32 – 36 g/dL Leukosit 3,6 – 11,0 103/uL Basofil 0 – 1 % Eosinofil 2 – 4 % Neutrofil 50 – 70 % Limfosit 25 – 40 % Monosit 2 – 8 % Trombosit 150 – 440 103/uL LED 0 – 20 mm/jam Waktuprotrombin 11,9 – 14,4 Detik APTT 23,6 – 34,8 Detik Fibrinogen 200 – 400 Mg/dL D-Dimer <500 Ng/mL GOT <27 U/L Gamma GT <39 U/L
Fosfatase Alkali 42 – 98 U/L
Cholesterol Total <200 mg/dL LDL Direk <100 mg/dL HDL >40 mg/dL Trigliserida <150 mg/dL Urean N 6 – 20 mg/dL SHBG 26,1 – 110 nmol/L TSHs 0,550 – 4,780 ulU/mL
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Nama Pemeriksaan NilaiRujukan Satuan
LH 3,26 mlU/m L FSH Follicular phase 2,5 – 10,2 Midcycle peak phase 3,4 – 33,4 Luteal phase 1,5 – 9,1 Perempuanhamil< 0,3 Postmenopausal 23,0 – 116,3 mlU/m L Free Testosteron Index 0,51 – 6,53 % Testosteron Perempuan 20-49: 8,4 – 48,1 Perempuan>50 : 2,9 – 40,8 ng/dL GTT Puasa <100 mg/dL GTT 2 Jam <140 mg/dL
Insulin Puasa 3,2 – 28,5 ulU/mL Prolaktin Tidakhamil: 2,8 -29,2 Hamil : 9,7 – 208,5 Postmenopausal : 1,8 – 20,3 ng/dL
Tabel 3. Daftar nama obat-obatan pada PUA-I
No Nama Generik Formulasi (Bentuk Sediaan, Kekuatan, dan Kemasan) Anti Fibrinolitik
1 Asam traneksamat
500 mg/tablet; 250 mg/kapsul; 50 mg/ml; 100 mg/ml (Kalnex®)
250 mg/kaps; 500 mg/tab film coated; 250 mg/5ml; 500mg/5ml (Transamin®)
Anti Inflamasi Non Steroid
1 Asam mefenamat 500 mg / tab; 500 mg/kaplet (Ponstan®), (Mefinal®) 2 Ibuprofen Tab 200mg, botol 100 tab Tablet 400mg, botol 100 tab
3. Asam asetil salisilat (Asetosal) Tab 100 mg, kotak10 blister@ 10 tablet Tab 500 mg, kotak 10 blister@ 10 tablet Estrogen Alamiah
1. 17 ȕ Estradiol 1 mg & 2 mg/tab
2. Estrogen ekuin konjugasi Tab 0,625 mg, kotak, strip 28 tablet Estrogen Sintetik
1. Etinil Estradiol 0.05 mg, 1 botol @ 100 tablet (Lynoral®) Progestin Sintetik
1. Didrogesteron Tablet 10 mg,1 strip 10 tablet
2. Desogestrel Tablet 0,075 mg, box 1 blister @ 28 tablet, box 3 blister@ 28 tablet (Cerazette®) 3. Lynestrenol Tablet 0,5 mg. box 3 blister @ 28 tablet (Exulton®)
Tablet 5 mg. Box 10 strip,@ 10 tablet (Endometril®) 4. Medroksi progesterone asetat Tab 250 mg, btl 50 tab Inj 200 mg/ml, kotak 1 vial 2,5 ml
3. Noretisteron Tablet 5 mg, Botol 30 tablet 4. Nomegestrol asetat Kaplet 5 mg, box 3 blister@ 10 tablet 5 Depo medroksi progestero nasetat Injeksi depo 150 mg
Pil Kontrasepsi Kombinasi
1. 17ȕ estradiol + Nomegestrol asetat (24-4 rejimen) Normogestrol acetate 2.5 mg + Etinil Estradiol 1,5 mg
2 Etinil Estradiol + Desogestrel (21-7 rejimen)
Desogestrel 0,15 mg + Etinil Estradiol 0,03 mg; box 1 blister @ 28 tablet, box 3 blister@ 28 tablet (Mercilon®) Desogestrel 0,15 mg + Etinil Estradiol 0,035 mg; box 1 blister @ 28 tablet, box 3 blister@ 28 tablet (Marvelon®)
Nama Pemeriksaan NilaiRujukan Satuan LH 3,26 mlU/m L FSH Follicular phase 2,5 – 10,2 Midcycle peak phase 3,4 – 33,4 Luteal phase 1,5 – 9,1 Perempuanhamil< 0,3 Postmenopausal 23,0 – 116,3 mlU/m L Free Testosteron Index 0,51 – 6,53 % Testosteron Perempuan 20-49: 8,4 – 48,1 Perempuan>50 : 2,9 – 40,8 ng/dL GTT Puasa <100 mg/dL GTT 2 Jam <140 mg/dL
Insulin Puasa 3,2 – 28,5 ulU/mL Prolaktin Tidakhamil: 2,8 -29,2 Hamil : 9,7 – 208,5 Postmenopausal : 1,8 – 20,3 ng/dL
Tabel 3. Daftar nama obat-obatan pada PUA-I
No Nama Generik Formulasi (Bentuk Sediaan, Kekuatan, dan Kemasan) Anti Fibrinolitik
1 Asam traneksamat
500 mg/tablet; 250 mg/kapsul; 50 mg/ml; 100 mg/ml (Kalnex®)
250 mg/kaps; 500 mg/tab film coated; 250 mg/5ml; 500mg/5ml (Transamin®)
Anti Inflamasi Non Steroid
1 Asam mefenamat 500 mg / tab; 500 mg/kaplet (Ponstan®), (Mefinal®) 2 Ibuprofen Tab 200mg, botol 100 tab Tablet 400mg, botol 100 tab
3. Asam asetil salisilat (Asetosal) Tab 100 mg, kotak10 blister@ 10 tablet Tab 500 mg, kotak 10 blister@ 10 tablet Estrogen Alamiah
1. 17 ȕ Estradiol 1 mg & 2 mg/tab
2. Estrogen ekuin konjugasi Tab 0,625 mg, kotak, strip 28 tablet Estrogen Sintetik
1. Etinil Estradiol 0.05 mg, 1 botol @ 100 tablet (Lynoral®) Progestin Sintetik
1. Didrogesteron Tablet 10 mg,1 strip 10 tablet
2. Desogestrel Tablet 0,075 mg, box 1 blister @ 28 tablet, box 3 blister@ 28 tablet (Cerazette®) 3. Lynestrenol Tablet 0,5 mg. box 3 blister @ 28 tablet (Exulton®)
Tablet 5 mg. Box 10 strip,@ 10 tablet (Endometril®) 4. Medroksi progesterone asetat Tab 250 mg, btl 50 tab Inj 200 mg/ml, kotak 1 vial 2,5 ml
3. Noretisteron Tablet 5 mg, Botol 30 tablet 4. Nomegestrol asetat Kaplet 5 mg, box 3 blister@ 10 tablet 5 Depo medroksi progestero nasetat Injeksi depo 150 mg
Pil Kontrasepsi Kombinasi
1. 17ȕ estradiol + Nomegestrol asetat (24-4 rejimen) Normogestrol acetate 2.5 mg + Etinil Estradiol 1,5 mg
2 Etinil Estradiol + Desogestrel (21-7 rejimen)
Desogestrel 0,15 mg + Etinil Estradiol 0,03 mg; box 1 blister @ 28 tablet, box 3 blister@ 28 tablet (Mercilon®) Desogestrel 0,15 mg + Etinil Estradiol 0,035 mg; box 1 blister @ 28 tablet, box 3 blister@ 28 tablet (Marvelon®)
68
No Nama Generik Formulasi (Bentuk Sediaan, Kekuatan, dan Kemasan)
3 Etinil estradiol + Levonogestrel (21-7 rejimen) Levonorgestrel 150 mcg + Etinil Estradiol 30 mcg
2. Etinil estradiol + Cyproteron asetat (21-7 rejimen) Cyproterone acetate 2 mg + Etinil estradiol 0.035 mg
3. Etinil estradiol + Drospirenone (21-7 rejimen) Drosperinone 3 mg + Etinil Estradiol 30 mcg
4. Etinil estradiol + Drospirenone (24-4 rejimen) Drosperinone 3 mg + Etinil Estradiol 20 mcg Susuk Kontrasepsi (Implan)
1 Implan 1 rod 68 mg etonogestrel (Implanon/ Implanon NXT®) 2 Implan 2 rods 75 mg levonorgestrel/rods
Alat Kontrasepsi Dalam Rahim (AKDR)
1 Levonorgestrel IUS (Intra Uterine System) Levonorgestrel 52 mg
2 Copper T (set/buah) T-shaped IUD dengan kawat tembaga Antibiotik
1 Doksisiklin Kapsul 100 mg (sebagai hiklat/HCL) Kotak 10 strip @ 10 kapsul
Daftar Pustaka
1. World Health Organization. Family Planning A Global Handbook for Providers-Evidence-Based Guidance Developed. 2011. Whqlibdoc.who.int/publications /2011/9780978856373 eng.pdf .
2. Biran Affandi. Penduduk Indonesia mencapai 273 juta tahun 2025. Antara . 11-11-2006. 3-2-2010.
3. Abdul Bari Saifuddin. Konseling dan Persetujuan Tindakan Medis. In: Biran Affandi, Moh.Baharuddin, Soekaemi Soekir, editors. Buku panduan praktis pelayanan kontrasepsi. 2 ed. Jakarta: Yayasan Bina Pustaka Sarwono Prawirohardjo; 2010. p. U1-U7.
4. Perkumpulan Kontrasepsi Mantap Indonesia. Hasil Muktamar IX, Surabaya 5 Agustus 2009. PKMI; 2010.
5. Schrager S. Abnormal Uterine Bleeding Associated with Hormonal Contraception.AmFam Physician. 2002 May 15;65(10):2073-2081.
6. Mansour D, Korver T, Petrova MM, Frase I. The effects of Implanon on mentrual bleeding patterns. The european Journal of Contraception and Reproductive Health Care June 2008;13 (S1):13-28
7. Faculty of Sexual and Reproductive Healthcare in collaboration with the Royal College of Obstetricians and Gynaecologists (RCOG). Management of Unscheduled Bleeding in Women Using Hormonal Contraception. 2009:1-16. www.fsrh.org/pdfs/unscheduledbleedingmay09.pdf
8. Wiegratz I, Stahlberg S, Manthey T, et al. Effect of extended-cycleregimen with an oral contraceptive containing 30 mcg ethinylestradioland 2 mg dienogest on bleeding patterns, safety, acceptance andcontraceptive efficacy. Contraception 2011;84:133–43.
9. Miller L, Hughes JP. Continuous combination oral contraceptive pillsto eliminate withdrawal bleeding: a randomized trial. Obstet Gynecol2003;101:653–61.
10. Himpunan Endokrinologi-Reproduksi dan Fertilitas Indonesia (HIFERI). Konsensus HIFERI, Bogor 24-25 agustus 2013
11. Marret H, Fauconnier A, Chabbert-Buffet N, Cravello L, Golfier F, Gondry J, Agostini A, Bazot M, Brailly-Tabard S, Brun JL, De Raucourt, Gervaise A. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 133–137 12. Munro MG,Critchley H, Fraser IA. The FIGO systems for nomenclature and
classificationof causes of abnormal uterine bleeding in thereproductive years: who needs them?Am J ObstetGynecol 2012
13. Munro MG, Critchley HOD, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertility and Sterility.2011.( 95) 7.
14. Kim KR, Peng R, Ro JY, Robboy SJ. A diagnostically useful histopathologic feature of endometrial polyp: the long axis of endometrial glands arranged parallel to surface epithelium. Am J SurgPathol. 2004;28:1057–1062.
15. Bird C, McElin T, Manalo-Estrella P. The elusive adenomyosis of the uterus revisited. Am J Obstet Gynecol. 1972;112:583–593.
16. Salman MC, Usubutun A, Boynukalin K, Yuce K. Comparison of WHO and endometrial intraepithelial neoplasia classifications in predicting the presence of coexistent malignancy in endometrial hyperplasia. J GynecolOncol. 2010;21:97–101
No Nama Generik Formulasi (Bentuk Sediaan, Kekuatan, dan Kemasan)
3 Etinil estradiol + Levonogestrel (21-7 rejimen) Levonorgestrel 150 mcg + Etinil Estradiol 30 mcg
2. Etinil estradiol + Cyproteron asetat (21-7 rejimen) Cyproterone acetate 2 mg + Etinil estradiol 0.035 mg
3. Etinil estradiol + Drospirenone (21-7 rejimen) Drosperinone 3 mg + Etinil Estradiol 30 mcg
4. Etinil estradiol + Drospirenone (24-4 rejimen) Drosperinone 3 mg + Etinil Estradiol 20 mcg Susuk Kontrasepsi (Implan)
1 Implan 1 rod 68 mg etonogestrel (Implanon/ Implanon NXT®) 2 Implan 2 rods 75 mg levonorgestrel/rods
Alat Kontrasepsi Dalam Rahim (AKDR)
1 Levonorgestrel IUS (Intra Uterine System) Levonorgestrel 52 mg
2 Copper T (set/buah) T-shaped IUD dengan kawat tembaga Antibiotik
1 Doksisiklin Kapsul 100 mg (sebagai hiklat/HCL) Kotak 10 strip @ 10 kapsul
Daftar Pustaka
1. World Health Organization. Family Planning A Global Handbook for Providers-Evidence-Based Guidance Developed. 2011. Whqlibdoc.who.int/publications /2011/9780978856373 eng.pdf .
2. Biran Affandi. Penduduk Indonesia mencapai 273 juta tahun 2025. Antara . 11-11-2006. 3-2-2010.
3. Abdul Bari Saifuddin. Konseling dan Persetujuan Tindakan Medis. In: Biran Affandi, Moh.Baharuddin, Soekaemi Soekir, editors. Buku panduan praktis pelayanan kontrasepsi. 2 ed. Jakarta: Yayasan Bina Pustaka Sarwono Prawirohardjo; 2010. p. U1-U7.
4. Perkumpulan Kontrasepsi Mantap Indonesia. Hasil Muktamar IX, Surabaya 5 Agustus 2009. PKMI; 2010.
5. Schrager S. Abnormal Uterine Bleeding Associated with Hormonal Contraception.AmFam Physician. 2002 May 15;65(10):2073-2081.
6. Mansour D, Korver T, Petrova MM, Frase I. The effects of Implanon on mentrual bleeding patterns. The european Journal of Contraception and Reproductive Health Care June 2008;13 (S1):13-28
7. Faculty of Sexual and Reproductive Healthcare in collaboration with the Royal College of Obstetricians and Gynaecologists (RCOG). Management of Unscheduled Bleeding in Women Using Hormonal Contraception. 2009:1-16. www.fsrh.org/pdfs/unscheduledbleedingmay09.pdf
8. Wiegratz I, Stahlberg S, Manthey T, et al. Effect of extended-cycleregimen with an oral contraceptive containing 30 mcg ethinylestradioland 2 mg dienogest on bleeding patterns, safety, acceptance andcontraceptive efficacy. Contraception 2011;84:133–43.
9. Miller L, Hughes JP. Continuous combination oral contraceptive pillsto eliminate withdrawal bleeding: a randomized trial. Obstet Gynecol2003;101:653–61.
10. Himpunan Endokrinologi-Reproduksi dan Fertilitas Indonesia (HIFERI). Konsensus HIFERI, Bogor 24-25 agustus 2013
11. Marret H, Fauconnier A, Chabbert-Buffet N, Cravello L, Golfier F, Gondry J, Agostini A, Bazot M, Brailly-Tabard S, Brun JL, De Raucourt, Gervaise A. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 133–137 12. Munro MG,Critchley H, Fraser IA. The FIGO systems for nomenclature and
classificationof causes of abnormal uterine bleeding in thereproductive years: who needs them?Am J ObstetGynecol 2012
13. Munro MG, Critchley HOD, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertility and Sterility.2011.( 95) 7.
14. Kim KR, Peng R, Ro JY, Robboy SJ. A diagnostically useful histopathologic feature of endometrial polyp: the long axis of endometrial glands arranged parallel to surface epithelium. Am J SurgPathol. 2004;28:1057–1062.
15. Bird C, McElin T, Manalo-Estrella P. The elusive adenomyosis of the uterus revisited. Am J Obstet Gynecol. 1972;112:583–593.
16. Salman MC, Usubutun A, Boynukalin K, Yuce K. Comparison of WHO and endometrial intraepithelial neoplasia classifications in predicting the presence of coexistent malignancy in endometrial hyperplasia. J GynecolOncol. 2010;21:97–101
17. Baak JP, Mutter GL, Robboy S, et al. The molecular genetics and morphometry-based endometrial intraepithelial neoplasia classification system predicts disease progression in endometrial hyperplasia more accurately than the 1994 World Health Organization classification system. Cancer. 2005;103:2304–2312.
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monophasic oral contraceptive containing 30 microgram ethinyl estradiol and 150 microgram desogestrel in Latin-American women. Adv Contracept1998; 14: 15–26. 44. Bannemerschult R, Hanker JP, Wunsch C, Fox P, Albring M, Brill K. A multicentre,
uncontrolled clinical investigation of the contraceptive efficacy, cycle control and safety of a new low dose oral contraceptive containing 20 micrograms ethinyl estradiol and 100 micrograms levonorgestrel over six treatment cycles. Contraception 1997; 56: 285–290. 45. Ferenczy A. Pathophysiology of endometrial bleeding. Maturitas 45 (2003) 114 46. Smith OP,Critchley HOD.Progestogen onlycontraceptionand endometrial
breakthrough bleeding. Angiogenesis. 2005 (8): 117-126.
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